Exogenous luteinizing hormone (LH) increases estradiol response patterns in poor responders with low serum LH concentrations

Evaluation of two doses of recombinant luteinizing hormone supplementation in an unselected group of women undergoing follicular stimulation for in vitro fertilization

OBJECTIVE

To evaluate the efficacy of two doses of recombinant (r)LH, 75 IU (recommended) or 37.5 IU, for follicular stimulation and outcomes in a randomized cohort of IVF patients.

DESIGN

Randomized, prospective analysis.

SETTING

Private hospital incorporating an established IVF center.

PATIENT(S)

Women undergoing IVF who had a body mass index >18 or <35 and no abnormal karyotype, anovulation, oligomenorrhea, or any known endocrinopathy/illness.

INTERVENTION(S)

Pituitary desensitization was achieved with triptorelin (0.1 mg SC), and gonadotropin stimulation was performed with either rFSH alone (group A) or in combination with rLH in one of two doses: 37.5 IU (group B) or 75 IU (group C), daily.

MAIN OUTCOME MEASURE(S)

A range of endocrinologic, embryologic, clinical, and outcome parameters were evaluated.

RESULT(S)

With rLH supplementation there was a significant increase in the incidence of implantation (9% for rFSH only [group A] vs. 11% and 16% with 37.5 IU rLH and 75.0 IU rLH [groups B and C], respectively) and clinical pregnancy (19% vs. 23% and 31%) (P<.01 and P<.04, respectively), whereas there was no difference in the multiple pregnancy rates. There was a significant (P<.001) increase in the total units of rFSH used in proportion to the amount of rLH supplementation (2,645 U vs. 3,475 U and 3,681 U) and in the level of peripheral E(2) on the day of hCG administration (1,049 pg/mL vs. 1,640 pg/mL and 1,226 pg/mL) (P<.001). There was no significant between difference in mean age, numbers of oocytes recovered, basal and downregulation hormone levels, or the incidence of fertilization in the absence or presence of rLH supplementation, but a higher incidence of grade 1 to 2 embryos was observed when rLH was supplemented.

CONCLUSION(S)

After pituitary desensitization, there was an increase in the incidence of implantation, clinical pregnancy, and delivery rates in patients stimulated with rFSH supplemented with rLH.

Randomized trial to compare the effect of recombinant human FSH (follitropin alfa) with or without recombinant human LH in women undergoing assisted reproduction treatment

Women undergoing intracytoplasmic sperm injection (ICSI) for male factor infertility were randomly assigned to receive ovarian stimulation in a long agonist protocol with a combination of recombinant human FSH (r-hFSH; Gonal-F) and recombinant human LH (r-hLH; Luveris) (n = 212) starting on day 6 of FSH stimulation until human chorionic gonadotrophin (HCG) at a daily fixed dose of 150 IU r-hLH, or with r-hFSH alone (n = 219). There was no significant difference in the number of metaphase II oocytes retrieved (10.3 versus 10.4) in patients treated with r-hFSH and r-hLH versus r-hFSH alone; however, more embryos were transferred in the LH-supplemented group (2.9 versus 2.8, P = 0.037). Overall, the implantation rates were 22.9 versus 27.0% in patients treated with r-hFSH and r-hLH versus with r-hFSH alone respectively (NS). The respective numbers of MII oocytes retrieved in patients <35 or >or=35 years were 11 versus 8.3 (P = 0.010) for patients treated with r-hFSH alone, and 10.7 versus 9.3 (NS) for those given supplemental r-hLH (150 IU) from day 6. Implantation rates in patients <35 years treated with r-hFSH were higher (30.7%) than those receiving r-hFSH and r-hLH, (23.5%) (P = 0.068). In patients >or=35 years, the implantation rates were 21.7% for those patients supplemented with 150 IU r-hLH from day 6 of stimulation versus 15.7% when treated with FSH alone (NS). Younger patients therefore do not seem to benefit from an LH-supplemented ovarian stimulation protocol, but women >or=35 years undergoing assisted reproduction may benefit from using r-hLH in addition to r-hFSH.

A pilot study of the use of low dose human menopausal gonadotropin in ovulation induction

OBJECTIVE

To evaluate the clinical efficacy of a combined regimen of follicle stimulating hormone (FSH) and low dose human menopausal gonadotropin (hMG) following GnRH agonist ultralong protocol in controlled ovarian hyperstimulation (COH) for in vitro fertilization and embryo transfer (IVF-ET).

STUDY DESIGN

IVF-ET was performed on 45 patients who had uterine or peritoneal factors, such as moderate to severe endometriosis, adenomyosis, or uterine myoma. The patients were randomized into two groups after the administration of long-acting GnRH agonist 2-4 times within a 4-week interval; highly purified FSH (FSH-HP) and hMG (Group A, n=26), FSH-HP only (Group B, n=19). hMG was administered at a fixed-dose of 75IU per day and the dose of FSH-HP was adjusted according to the patient's individual response. The results of COH and IVF-ET were assessed and compared between the two groups.

RESULTS

Serum estradiol (E2) level on hCG day was significantly higher in Group A (1418.2+/-920.2 pg/ml, mean+/-S.D.) than in Group B (678.4+/-457.8 pg/ml) (P<0.05). The clinical pregnancy rate and implantation rate tended to be higher in Group A than in Group B; 23.1% (6/26) versus 10.5% (2/19), 11.0% (9/82) versus 4.6% (3/65).

CONCLUSION

In COH for IVF-ET using GnRH agonist ultralong protocol, the combined treatment of FSH-HP and low dose hMG showed a higher serum E2 level when compared with treatment with FSH-HP alone.

[Revisiting the role of LH in follicular development]

During the last decade, two pivotal events widened the gap between the hormonal dynamics of ovarian stimulation and that of the menstrual cycle. First, the profound and routine suppression of endogenous gonadotropins by GnRH analogues used in ovarian stimulation pressed us to recreate the hormonal environment necessary for adequate follicular maturation and steroidogenesis. Second, drugs with reduced or null LH activity became available, based on the hypothesis that FSH action was sufficient to follicular development and maturation irrespective of residual endogenous gonadotropin levels. Today, there is a renewed interest in the possible role of LH on follicular development, in an effort to mimic the hormonal events of the menstrual cycle to optimize ovarian stimulation outcome.

Is luteinizing hormone needed for optimal ovulation induction?

The role of luteinizing hormone in the natural menstrual cycle is not disputed. There are, however, a variety of opinions regarding the potential role of exogenous luteinizing hormone in ovulation induction and whether it is actually needed. The recent introduction into clinical practice of recombinant gonadotropins has been paralleled by recent advances in the knowledge of the endocrine and paracrine mechanisms that regulate human folliculogenesis. On this basis, this review analyses whether or not all patients need luteinizing hormone for follicular growth stimulation. In addition, new opportunities for improved treatment are considered as a result of the availability of recombinant human luteinizing hormone both in patients with ovulatory disorders and those undergoing multiple follicular development for assisted reproduction.

Stimulation protocols for poor responders and aged women

There is a general consensus on the clinical fact that the more embryos replaced the higher pregnancy rates are achieved. For this reason those IVF cycles with a low response and a reduced number of oocytes and embryos will have very few chances of producing a pregnancy. It is very important to diagnose, by means of the anamnesis and hormonal tests which patients are most likely to present a poor response to conventional ovarian stimulation protocols. It is mandatory to know the patient's plasmatic levels of FSH and estradiol together with personal data such as the age and the previous history of the patient. Only young poor responders with a normal basal hormonal profile will have some chances that by applying new protocols and combining new drugs, improve their response and have higher pregnancy rates. For the old poor responders who have already failed to alternative protocols including natural cycles, oocyte donation is the last and best hope.